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onnunign Envelope ID: 1**noenn-0o44-4Ao1*eec-3n4xFoecAc41 <br /> EXHIBIT <br /> PROVIDERS OUTSIDE AGENCY APPLICATION <br /> d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION <br /> CLAUSE <br /> Are any of the Board Members or employees of the agency which will be carrying out this program <br /> or members of their immediate fanni|ies, or their business associates... <br /> YES NO <br /> | | ■ a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> I- El b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> c) Current beneficiaries of the project/program for which funds are requested? <br /> EZ d) Paid providers of goods or services to the program or having other financial <br /> interest in the program? <br /> If you have answered YES to any questinn, please provide a full explanation below. <br /> One of CCSA's board members, Adriana K8mrtinez, is the owner/director of a child care tgoi|ib/. <br /> Spanish for Fun Academny, which provides child care services to CCSA child care scholarship <br /> recipients. The facility receives monthly reimbursement for these services. <br /> NON-DISCRIMINATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies to the parties <br /> hereto for thernae|ves, their mQen1s, offic/o|s, employees and servants agree not to discriminate in <br /> any manner of these basis of race, color, Qendmr, national origin, age, hmndiomp, re|igiun, sexual <br /> orientotion, gender identity/expression, familial status or veterans status with reference to any <br /> activities carried out by the 8rmntee, no matter how remote. The parties hereto further agree in all <br /> respects to conform to the provision and intent of Orange County Civil Rights (]rdinonoe, as <br /> amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for <br /> specific perfonnonce, injunctive re|ief, or other remedy as by law provided; this provision shall be <br /> binding on the Qrmnteam, the successors and assigns of the parties hereto with reference to the <br /> above subject manner. <br /> To the best of my knowledge and belief all of the above information is true and current. I <br /> acknowledge and understand that the existence of a potential conflict of interest does not <br /> necessarily make the program ineligible for funding, but the existence m undisclosed <br /> conflict result in the termination of any grant awarded. <br /> Signature: <br /> / _� -> -7_-� /7 <br /> ,seoutiveOireotor Date <br /> Signature: ` NN |�^ � �A��^ <br /> =�8 � ^ --- "w,�`��'� _--- ' <br /> Boar. �.'°-rsun D" / \~ ^ <br /> AGENCY INFORMATION 1/27/2017 8:51:47 AM I <br />